Provider Demographics
NPI:1104096163
Name:SHELTON, VICKI D (MSCCCSLP)
Entity type:Individual
Prefix:
First Name:VICKI
Middle Name:D
Last Name:SHELTON
Suffix:
Gender:F
Credentials:MSCCCSLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:147 NICKLIN COURT
Mailing Address - Street 2:
Mailing Address - City:HEDGESVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:25427
Mailing Address - Country:US
Mailing Address - Phone:304-754-7665
Mailing Address - Fax:
Practice Address - Street 1:247 HARRISON AVENUE
Practice Address - Street 2:MORGAN COUNTY BOARD OF EDUCATION
Practice Address - City:BERKELEY SPRINGS
Practice Address - State:WV
Practice Address - Zip Code:25411
Practice Address - Country:US
Practice Address - Phone:304-258-2014
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-03-06
Last Update Date:2008-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV0494235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0152165000Medicaid